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�f _rERICKSON ... ,F.•; Z 3 9 C: <br /> _J 255 Parr Boulevard, Richmond, California 94801 s J J <br /> (510) 235-1393 • FAX (510) 235-3709 <br /> NON -HAZARDOUS WASTE DATA FORM <br /> NAME TJ( '� �i f r✓Jl`'�p/�{I����g M1-�_T1� /� !�•- I1' 1 1 Lam' ( 7I I.iA <br /> ADDRESS�.L�r1ti1� V Cs• J 1 e,./../�F•'�{s, - NO. <br /> CITY,STATE,ZIPV�t7 C.- y� cA PHONE NO. �Y S'7L/^ <br /> ¢ CONTAINERS:No. VOLUME WEIGHT <br /> ¢ TANK DUMP <br /> W TYPE ❑ 13. TRUCK TRUCK ❑ DRUMS ❑ CARTONS W..OTHER <br /> Z I <br /> LU 'WASTE DESCRIPTION Up JAN ` GENERATING PROCESS <br /> } COMPONENTS OF WASTE _ PPM % COMPONENTS OF WASTE PPM % <br /> ca <br /> Uj OIL <br /> W <br /> J } ' <br /> a 2 6. <br /> O <br /> iJ 3 7. <br /> W <br /> m <br /> 4 a. <br /> O <br /> H [IPROPERTIES. PHS 12,SOLID ❑ LIQUID ❑ SLUDGE ❑ SLURRY ❑OTHER <br /> HANDLING INSTRUCTIONS <br /> THE GENERATOR CERTIFIES THAT /7 j _ / <br /> THE WASTE AS DESCRIBED IS 100% /\ �• /- f ',' -'J- L, / ��'��i �[ ... �:' <br /> TYPED OR PRINTED FULL NAME 8 SIGNATURE - r <br /> /' - /7 EPA <br /> ¢ NO. <br /> � LC�l . ) 7th k /ll (_`_ I( _)L D �, 4 > <br /> cc NAME <br /> ¢ ADDRESS ,� I(�' ��•+ ✓ SERVICE ORDER NO. <br /> O <br /> a � <br /> W CITY,STATE.ZIP 1 �n1 �AO([I 11 �- <br /> Z /- �1 PICK UP DATE <br /> /LD <br /> ¢ PHONE NO. (-S 1'._.Z <br /> TRUCK, UNIT. I.D. NO. TYPED OR PRINTED FULL NAMt 8 SIGNATURE DATE <br /> /J", ,A� ,�, ],..r. EPA <br /> NAME_ V �� J !(\ y NO' <br /> (� � DISPOSAL METHOD <br /> >- ADDRESS �• "n+ �' E V �"�- �i!`T L.- V F ❑LANDFILL ❑OTHER <br /> J CITY.STATE.ZIP AIN ,0551'r l � / (rT 1) CA 93246 ll <br /> LL PHONE NOiL- <br /> . �1-� <br /> p , <br /> fTYPED OR PRINTED FULL NAME 8 SI NATURE ( DATE <br /> GEN _ OLD/NEW L A TONS / <br /> TRANS S B - <br /> Ci0 RT/CD HWCF NONE DISCREPANCY <br /> CPE)E7 <br />